Cozeva User Request

Please complete the form to obtain access to our quality platform. Should additional information be required we will contact you at the e-mail provided.

Platform*

* Please select all that apply from the drop down menu. If you are requesting access to multiple platforms, you will receive welcome emails from Cozeva for each.

Select

IPA/Medical Group:*

* If provider belongs to multiple groups, please select all that apply from the drop down menu.

Select

Provider Name:*

* If you are requesting access to all providers within a Practice/Clinic, please indicate ALL in this field.

Provider NPI:

Clinic Name:*

Clinic TaxID:

User's First Name:*

User's Last Name:*

Title/Position:*

E-Mail Address:*

Notes:

TERMS AND CONDITIONS Acceptance of these Terms and Conditions is required to use Cozeva at MedPOINT Management for business purposes. Use of this platform is intended for the individual to which access has been granted. Login credentials must not be shared. This platform may contain information that is privileged, confidential, related to personal health/healthcare or otherwise exempt from disclosure under applicable law. By clicking the "I Accept" button you agree that any dissemination, distribution, or copying of any information without permission of the originator is strictly prohibited. If you have questions concerning these terms and conditions or log in credentials, please contact MedPOINT's Compliance Department.

I Accept*

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